Gordon Brown: Once again, he proves to the whole country that there is absolutely no substance in anything that he says. We have to clean up the electoral system, and we are doing that. We are cleaning up the expenses system. The second thing that we are doing is cleaning up the economy and ensuring that it comes out of recession. The party opposite has no policies to deal with that. It is words, words and words. We will get on with the action.

Gordon Brown: That is not correct. Thousands of people are being helped with the various schemes. The first is the mortgage income support scheme for people who are unemployed, which is now available for those with houses worth under £200,000, and large numbers of people are claiming that. The second is the moratorium that is available on people's building society and bank payments, which we negotiated with building societies. The third is the shared equity scheme, where we are prepared to buy a share of the house to help people move forward. Discussions on that are moving forward for large numbers of people. The fourth is the measures that we are taking to deal with the way in which the banks approach mortgages in the first place.
	The recent report of the Council of Mortgage Lenders said that they expected repossessions to be far less than they had predicted, as a result of the action that we are taking. Any repossession is to be regretted. There are many circumstances in which repossessions happen—for example, if there is a family break-up which is nothing to do with the financial situation of an employee—but there are other situations where repossessions are caused by the lack of money. We are trying to help those people to maintain their mortgages and renegotiate them. I think the hon. Gentleman will find that no Government have done more to help mortgage payers to prevent repossessions. That is what a Labour Government are about. We will not walk by on the other side.

Mark Lazarowicz: I am sure that my right hon. Friend will have seen the latest scientific report showing that by the end of the century, global warming will be even more severe than previously thought. We have gone beyond the stage at which we can stop irreversible damage to our planet, and now the question is whether we can stop environmental catastrophe. What will my right hon. Friend do to ensure that the G8 summit, which is coming up shortly, recognises that point, so that we have the chance in Copenhagen to get the type of agreement that the planet so desperately needs?

Iain Duncan Smith: I rise because there are concerns in my area in north-east London, which are shared, by the way, across the Floor of the House by the hon. Members for Leyton and Wanstead (Harry Cohen) and for Walthamstow (Mr. Gerrard) who are both with me on this. We believe that the process by which decisions are made on hyper-acute services is not at all transparent or clear. We have tried to press those responsible on whether the process is set in stone. They say that it is, but then they change it. For example, the Royal London hospital received a decision on hyper-acute services on the basis that it had a cardiac centre aligned, yet its scores were no better than Whipps Cross hospital. Queen Elizabeth hospital got a decision because of its neurological service, but it has no cardiac service aligned, while others are ruled out on the basis that, somehow, they have neither of those things. It seems that decisions are made on the basis of picking winners, rather than on having a set, transparent form that says, "If you have these things, you are likely to get it and we will adjudicate you accordingly." Will the Minister look at that carefully and ask Richard Sumray and his group how they reach such conclusions? Does she think that they are fair?

Andrew Lansley: My point is not about London. To return to what the Minister said about the rapid response associated with the FAST test, the way in which the ambulance service responds is very important. We know from the original work in Newcastle that ambulance staff are entirely capable of making as good a judgment about whether somebody may have had a stroke as GPs are. However, a recent report in the  Emergency Medicine Journal showed that the software used by ambulance staff to triage calls was missing up to half of potential strokes, that only one in four stroke patients were given a category A ambulance response and that in a minority of cases—3 per cent.—potential strokes were given category C responses. Is it the Government's view that we should seek to improve those figures and, in particular, to give possible strokes a category A response?

Andrew Lansley: First, may I welcome the debate and the opportunity it provides to consider the development of stroke services? It comes at an opportune moment, because, as the Minister said, it is approaching two years since we last had a debate whose purpose was to identify what needed to be done. At that point, the Government had just published their document, "A New Ambition for Stroke", but that was already more than a year and half after the National Audit Office had published its groundbreaking study of the delivery of stroke services. I remind the House of the work done by the NAO and by the Public Accounts Committee and I welcome the fact that the NAO is in the process of reviewing its report and the progress made on the strategy. That will be immensely helpful.
	Our debate is also timely in the sense that, two years ago, we looked at the outcome of the 2006 national sentinel stroke audit, and now we are able to consider the results of the 2008 national sentinel stroke audit, which was published in April this year. This is a timely opportunity to look at the progress made. I am pleased to note from the 2008 audit that an improvement has been recorded in all the standards in respect of the hospital care of stroke patients in England. That illustrates the amount of work done by the Department of Health, health services and hospitals across the country after the findings of the original NAO report.
	The Minister kindly expressed gratitude for the work done by the all-party group. As chair of that group, I would like to thank the Department for its unstinting support and I also thank hon. Members across the House for their participation. It is excellent that we have been able to work together to create an environment for the improvement of stroke care.
	As I have said before, I wish it were not necessary for the Department of Health to publish a national stroke strategy in order for hospitals across the country to identify on the basis of clear research evidence the best available treatment for stroke patients. As we will discuss in the debate, we unfortunately remain in a health service where the central structure of guidance and incentivisation has had a big impact on the extent to which hospital and community services are reconfigured. I promise my hon. Friends that I will touch on how the reconfiguration has worked out in London, for example.
	The Minister did not tell us in detail what the national sentinel audit said about the improvements, so I shall take a little time to put some of the key results on the record. First, as I have already said, the improvements recorded on all the set standards have taken the cumulative score in England up to 73 per cent.—a considerable improvement on 2006. Only a small number of hospitals have failed to improve. I do not want to diminish in any way the progress that has been made, but it is important for us constantly to look at the gaps between where we are and where we ought to be. For example, 25 per cent. of patients do not get access to a multidisciplinary stroke unit, yet the incontrovertible evidence is that such access gives patients better outcomes. We want to get increasingly close to 100 per cent. on these figures.
	My hon. Friend the Member for Westbury (Dr. Murrison) made an important point about the need to question why only 17 per cent. of patients reach a stroke unit within four hours. If patients have been admitted to an emergency department first, it is clearly not in their best interests to be sent to a medical admissions unit before being sent to an acute stroke unit. I recently visited Peterborough hospital, which has structured its services so that patients brought in in an ambulance are directly admitted to a stroke unit, bypassing the emergency department. I do not know whether that is the right approach given that many emergency departments are perfectly capable of dealing with stroke patients in the first place and ensuring that they get an immediate CT scan. However, I cannot see the benefit of patients being transferred to a medical admissions unit, and then being transferred to a stroke unit. It is not in the best interests of patients to be moved from one place to another within a hospital. Given that probably about 60 per cent. of stroke patients are admitted to a hospital on the same day as suffering the stroke, a much higher proportion should be sent to a stroke unit directly.
	The Minister spoke about the FAST test. The national sentinel stroke audit suggests that in 2008 only about a quarter of patients in total, in the sample, were subject to a FAST test by paramedics. That procedure needs to be embraced, not least because we have rightly told the public about the necessity of identifying the symptoms of stroke and treating such patients as a medical emergency. The last thing that should happen is that the public and patients do not see precisely those criteria being applied by ambulance services, by out-of-hours services—in whose protocols there is often a gap in terms of categorisation of stroke—and when patients are subsequently admitted to a hospital.
	That brings me to the point about immediate scanning. The evidence is clear that it is in stroke patients' best interests to receive a CT scan rapidly. In response to the audit, the Royal College of Physicians said that all patients admitted to hospital with a stroke or potential stroke should be scanned within 24 hours. As the Minister will know, in the absence of a CT scan, it is difficult to ascertain what kind of treatment a patient should receive. At a basic level, a stroke might be either ischaemic, resulting, for example, from a clot travelling to the brain, or haemorrhagic, from a bleed in the brain. As clinicians will make clear, unless one knows which type of stroke is involved as a result of a definitive scan, it is difficult to provide the appropriate treatment. As a proxy for providing good treatment, early CT scanning is integral.
	The audit suggests that only 64 per cent. of such patients were being scanned within 24 hours. Almost by definition, a large number of the rest were not able to get appropriate treatment as rapidly as they should have. Only 21 per cent. were being scanned within three hours—we would not expect that to be possible for 100 per cent., not least because for many patients admitted it would be clear that their stroke occurred more than three hours before, so the option of thrombolysis probably would not be available. In 2008, barely 1 per cent. of stroke patients—and fewer than 10 per cent. of those for whom it would be appropriate—were being thrombolysed. That is a long way from where we need to be. Even four or five years ago, countries such as Australia were approaching 15 per cent. of total stroke patients being thrombolysed, which is nearly the optimum level. Therefore, although we are making progress, we have further to go.
	The national sentinel audit looks at nine indicators, which are intended to represent a bundle of care that, if provided to patients, will be indicative of good quality. Thrombolysis is not included, because it is only appropriate for a minority of patients. However, many of the items mentioned by my hon. Friends are included: for instance, the swallow assessment, to which my hon. Friend the Member for Buckingham (John Bercow) referred. Interestingly, only 17 per cent. of patients surveyed in the national sentinel audit received all nine indicators of care. There is significant variation. For example, 69 hospitals achieved all nine indicators of care—the full care bundle—for fewer than 5 per cent. of their patients; in contrast, three hospitals achieved more than 70 per cent. As the audit points out, there is a big gap between those three hospitals and most of the others, which are bunching around 40 to 50 per cent. The three hospitals concerned are King's College hospital, the Royal Free and Chelsea and Westminster.
	That takes me on to London and the structure of its services. Undoubtedly, there is discussion to be had about where patients should be admitted for hyper-acute stroke care, immediate CT scanning, possible thrombolysis and so on. If we reform stroke services, we want that to be readily available. However, the approach differs across the country. As far as I can tell, NHS London's approach was to ask an expert panel to assess the quality of care in a large number of hospitals across London, to establish whether they were capable of providing good-quality care: in effect, whether they should be commissioned for hyper-acute stroke care. Having spoken to someone on the expert panel, I know that it reached views on that, but then NHS London said that eight hospitals would be designated as hyper-acute centres. For the life of me, I cannot find out why the answer was eight.

Andrew Dismore: The hon. Gentleman referred to the question of the Royal Free. Because I was concerned about it as well, I asked the Royal Free about it, and was told that it had accepted the proposals. It said that it had
	"considered... the preferred solution... in the consultation document... that the trust should work collaboratively with UCLH to provide a combined offer which has the potential to deliver a truly world class service. Having taken the advice of its clinical community it now endorses the UCLP proposals which would see a combined comprehensive service with one hyper-acute stroke unit... based at UCLH."

Andrew Lansley: Yes, I was about to discuss prevention. I am sure that the vascular risk assessment will provide a significant benefit in identifying people for whom there is scope for prevention. It would be helpful if, when the Minister speaks about the number of lives that will be saved, the Department had responded to my requests for the supporting data to be published to justify those figures. I am sure that, now that she has mentioned them in the House, all the data to support those figures will be published.
	There is still a job to be done in understanding, if people access vascular risk assessments, what the appropriate follow-up will be. We must be sure that we do not have a lot of people who become "worried well". They may need an improved diet or physical activity—hopefully, they will not need medication to which they do not have access. We must ensure that the necessary resources to support primary prevention are put in place.
	On prevention, an NOP poll from October last year showed that nearly one in five of the public still had no knowledge of the causes of stroke. It is important that we address that. There is good evidence to study. The World Health Organisation Monica—multinational monitoring of determinants and trends in cardiovascular disease—study published in  The Lancet Neurology in 2005 made it clear that if we are going to improve stroke care
	"socioeconomic factors seem more important than classic risk factors for the establishment of stroke trends in the population"
	Therefore, the argument that we have often discussed here about the reduction of inequalities involves not just health inequalities in isolation—classic socio-economic determinants of health are important in determining the level of stroke mortality.
	It is also important, and we can now see the benefit coming through, to note that one of the lessons of that study was that the
	"quality of stroke care makes a profound difference, not only to the patient and his or her family but also to the burden of stroke in the population at large."
	What does that mean? I think that it means that by educating people in the NHS and beyond about the causes of stroke, its symptoms, the necessity to treat it as a medical emergency and the possibility of being able to impact positively on it through treatment, we are making people more aware of the risk, the disability, the mortality associated with stroke and the fact that they can do something about it. That will, I hope, make a big difference to stroke mortality.
	We need to improve outcomes. It is not that we spend less on stroke; we spend a lot on it. However, for too long too much of what we have spent has been expenditure as a consequence of the disability that results from strokes. Too little has been spent to ensure that we prevent stroke and that where stroke occurs we access treatment rapidly.
	There are still significant disparities between treatment in this country and in others. There is still more we can do. It is not just about thrombolysis. It is also about early supported discharge. Only about a third of patients get access to early supported discharge after a stroke. We need that figure to rise. There is a continuing agenda, which we will continue to support and press for to improve stroke services and make their quality more consistent across the country. I hope that through prevention and awareness of stroke, stroke outcomes will further improve in the years ahead.

Laura Moffatt: I thank the hon. Gentleman for that intervention, but I believe that the health services move so quickly that in three years' time we will have moved on to new campaigns. I certainly hope the FAST campaign becomes part and parcel of our understanding as citizens of what can happen to people. I see it very much in the same terms as the seat belt campaign in that there is an initial start-up process, but the point then becomes embedded in our psyche and in our understanding of how we address things. I am fairly certain that there will come a time when we do not need a stroke campaign, but that we will then have to focus on other causes.
	We have talked about the need for a quick and adequate response for those with stroke, and it will be a disappointment to all Members if that falls short of the excellent stroke strategy requirements for treatment. I do not think any of us would shy away from being a critical friend of the NHS if that were necessary, and from trying to make the situation right if it had gone wrong. All of us would happily highlight these campaigns in order to make sure that all our constituents got the service they deserved if they were affected by stroke.
	I believe the stroke strategy has given focus to the whole stroke campaign and an understanding of where we are going with it. Interestingly, in a recent review of health services in the north of west Sussex, stroke was one of the principal issues that was addressed to try to strengthen our services. Crawley hospital has an amazing stroke unit; people come to it quickly after their initial treatment and there is a great sense of camaraderie. The staff are tremendously well motivated and qualified to deal with stroke.
	The Minister will completely understand my second plea to her, as she is a former nurse, and once a nurse, always a nurse. Stroke mainly affects people who are over 55, and more commonly over 65, and the treatment of it should be a well-respected specialism that takes its rightful place alongside all other emergency care. Those who deal with stroke should be well regarded by those within the wider profession and be regarded from outside the profession as engaged in a field that contributes enormously to well-being. It is not a second-class field. Those in the nursing profession used to say, "Oh well, I'm going to go and look after older people." That should be seen as up there with the most interesting of services. By making sure there is such high regard, we will be able to ensure that the service continues to improve and attracts the very best quality nurses.
	To make sure that that happens, we must ensure that the professionals in our communities come together. In February, my right hon. Friend the Secretary of State launched a well-being programme in Crawley, dedicated to ensuring that people are exercising, that they are dealing with issues such as hypertension, which of course is associated with one of the highest predispositions to stroke, that such conditions are being properly monitored and that diet is being addressed. We also know that those who are obese have a predisposition to stroke. This is about tackling all those issues at a very basic level within our primary care services and about our emergency services coming together to ensure that people are less affected by this horrible condition.
	When somebody has a stroke and receives the initial treatment—we hope that goes well and that the damage to the brain is reduced—we must ensure not only that they get the care in hospital that they desperately need but that it continues. Local authorities have a huge role to play in ensuring that timely adaptions are done at home, but co-ordination can sometimes be a difficult issue for local authorities to face. They need to ensure that when people are at home—be it in their own private home or in local authority or social housing—and needing to stay mobile, because that is crucial following a stroke, the adaptions are done in a timely fashion so that life is at least decent for them.
	We want to ensure that throughout the service, from the first moment that horrible event happens to when people start to make progress through speech therapy and physiotherapy, things are as good as they possibly can be. The way we can properly tackle this is by ensuring that more research is done. The Stroke Association is a great advocate of ensuring not only that the research is done but that people are treated properly, and it does excellent research in all sorts of areas. The Minister may be interested to learn that because of the work being done in Crawley, the Stroke Association gave SECAmb a beacon of good practice award. That is something of which we can be justly proud in our area.
	That is not to say that we are going to rest on our laurels, because we must continue to fight for better services for people who have a stroke. We must make sure that the emergency care is as it should be; we must continue to do much more preventive work; we must ensure that everybody within the professions is up to speed, and that includes GPs, nurses and practitioners throughout the national health service and beyond; we must improve the co-ordination of services when people return home, to ensure that adaptions are done in a timely fashion; and we must support the excellent voluntary groups, which make life better for those who have had a stroke, allowing them to come together with others to share experiences and to laugh and cry together over what can be a devastating event for a family. That is so important, and those groups are such a crucial element to all the work, as the Minister has said. In that way, we can genuinely ensure that people who suffer a stroke in the United Kingdom—and in England and Wales in particular—will have the best possible outcome following what can be the most appalling thing that can happen.

Greg Mulholland: I thank my hon. Friend for that valuable and important contribution, which addresses a point that I was about to make. I echo his comments in asking the Minister, in light of the extra volume of calls, what additional help hospitals and voluntary organisations are being and will be given, so that they can cope with the very welcome additional strain that has resulted from the success of the campaign. That is an important area for the Minister to concentrate on.
	Do the Government intend to do any quantitative analysis of the success of the campaign? I think that it would be very insightful. As has been mentioned by the hon. Member for Crawley (Laura Moffatt), have they considered the impact on particularly high-risk groups, such as those in certain black and minority ethnic communities—in particular those from south Asian or Afro-Caribbean communities? If the Minister can give us some indication of how the Government plan to target those particularly at-risk groups, that would be very useful.
	Let me turn to prevention. Hon. Members have already said that that is absolutely crucial. When we consider that 20,000 strokes a year could be avoided through preventive work on high blood pressure, irregular heart beats, smoking cessation and the wider use of statins, we see that prevention is an absolute priority in dealing with strokes. Again, if we consider the economic impact, preventing just 2 per cent. of strokes in England would save £37 million of care costs. That is a matter that needs even higher priority in the strategy.
	I welcome the NHS health check programme. It can highlight those most at danger from stroke, as well as those at danger from other conditions. How many people have been invited to these health checks, and are the most at-risk groups—the most susceptible groups—being invited? That is crucial, if the checks are to have the kind of impact that we all hope that they will in reducing the number of strokes that happen in the country.
	On treatment, as has already been mentioned the most crucial thing for stroke patients is to arrive swiftly at a stroke unit. The concerns that suspected stroke patients are not being prioritised sufficiently within the ambulance service are very real. In terms of the provision of CT scans and thrombolysis, the importance of specialist stroke units cannot be overstated. The Stroke Association has described stroke units as
	"the single most beneficial intervention that can be provided after stroke".
	As other hon. Members have said, however, there are disparities in care between those who are admitted immediately to stroke units and those who spend time on general wards or in accident and emergency departments. The simple fact, borne out by the figures, is that patients who are admitted to stroke units quickly are more likely to survive and to make a better recovery. Again, if we consider the costs, the impact on patients and the length of time involved, such patients will spend less time in hospital than their general ward counterparts, who have a 14 to 25 per cent. higher mortality rate.
	The 2008 Royal College of Physicians audit shows that there has been a huge increase in the number of hospitals that have protocols for ambulance service emergency transfer of patients to stroke units from 4 per cent. in 2004 to 49 per cent. in 2008. That is extremely welcome, but, as we have already heard, it is not happening up and down the country. I make reference to the particular concerns in London and echo the concerns about the somewhat arbitrary natures of the decisions that appear to be being taken.
	The provision of thrombolysis, as has been mentioned, is much too limited. I hope that the Minister will agree that that is an area where the strategy so far is not achieving what we all hope that it will achieve. Last year, only 8 per cent. of patients received thrombolysis, even though 15 per cent. of patients were eligible for that kind of treatment. Both CT scans and thrombolysis fall below National Institute for Health and Clinical Excellence standards.

Greg Mulholland: I apologise and thank the hon. Gentleman for that correction. I meant to say 0.8 per cent. and appreciate the intervention. May I echo what the hon. Gentleman has said about the inadequacies in CT scans and thrombolysis? NICE guidelines clearly state that all patients should be scanned, diagnosed and treated with thrombolysis, if required, within an hour. We have to acknowledge that we have a long way to go before we achieve that.
	Treatment of mini-strokes—TIAs—has already been mentioned. Effective treatment of TIAs is very important, as the risk of having a stroke within the first four weeks of a TIA is 20 per cent. According to the 2008 RCP stroke audit, only 45 per cent. of hospitals meet the stroke strategy's recommendation of investigating and treating high risk TIA patients within 24 hours, which means that 55 per cent. of them are not doing so. Again, there is a lot of work to do on that, and I ask the Minister to give us her thoughts on how the figure will be improved.
	After-stroke care is the final area of focus in this debate. There are real concerns about stroke patients—and indeed their families, who clearly have an important role to play in the rehabilitation and care of stroke patients—not yet having their needs fulfilled in that regard. After-stroke care is essential to regaining and relearning skills, sometimes even basic skills of everyday living. Rehabilitation is therefore absolutely essential. There have been improvements in that area, but even so, only half of stroke survivors receive rehabilitation in the first six months after discharge, and only a fifth do so in the next six months. I am afraid that it is an area in which, so far, the strategy is simply not delivering.
	Post-hospital rehabilitation needs to be organised while the patient is still in hospital, and not when they are discharged, and that has to be addressed. For example, home adaptations clearly have to be done before a patient returns home, so that they can carry on living their life, which is what we very much wish them to be able to do. The provision of information is an easy, cheap way to assist in the important process of rehabilitation, but there need to be improvements to that, too. The stoke audit of 2008 that I mentioned found that there had been little progress since 2006 in improving the amount of information given to patients and carers in hospital about reducing the risks of a further stroke. Of course, the whole purpose of rehabilitation is not just recovery, but prevention of further strokes. Some 58 per cent. of those patients for whom diet advice was applicable are recorded as having received it, and much of the information that is provided is not particularly helpful. A survey carried out by the Healthcare Commission, admittedly back in 2005, found that only 55 per cent. of patients understood the information that they received in hospital.
	I now come to the issue of care for those who are not able to return home. The voluntary sector does a wonderful job in many cases, assisting people in coming to terms with life after a stroke, yet the resources are simply not there, as is the case, I am afraid, for a great deal of social care for people recovering from conditions. I ask the Minister whether it is not time for the Government to consider making more resources available to voluntary groups to enable people to carry on living their lives in the community, or in specialist homes, if that is what medical professionals deem that they need. The whole issue of social care needs more work, and I ask the Minister to address the issue in her comments.
	I welcome the opportunity for this debate. I hope that we can have such debates at regular periods throughout the 10-year strategy, no matter which party is in government. It is important that all of us with an interest in this area of health care continue to monitor the implementation of the strategy, because all of us in all parts of the House are absolutely committed to ensuring that stroke care is a priority for the health service, and is very much at the top of the health policy list. All of us will continue to have that commitment, and we want the strategy to succeed.

Andrew Dismore: I particularly want to address the issue of the expansion of stroke services in London, on which Healthcare for London has recently been "consulting" as part of its stoke and major trauma consultation exercise. I put "consulting" in inverted commas, as it has been such a botched consultation that the public see that expansion of services as a cut. In my area, we have seen the unsightly picture of one NHS body advertising and lobbying against another, adding to the atmosphere of confusion and disinformation all round, and turning what should be a positive story into a negative one. Members of Parliament have been kept somewhat out of the loop, too.
	Barnet and Chase Farm Hospitals NHS Trust wrote to me on 7 April to plead its case, as opposed to that of Northwick Park hospital, for being one of the proposed eight hyperacute stroke units, on the basis of its location. Its letter refers to its existing transient ischaemic attack centre and the need for a local stroke unit. It implied that current services would go as a result of the changes, but of course they will not; they will be continued, as will the services provided by TIA centres and local stroke units everywhere else, and certainly in my area.
	Barnet and Chase Farm Hospitals NHS Trust then took out a full-page advertisement in the local newspaper—an advertisement that I can describe only as a scare story. It somewhat irresponsibly implied that cuts, which are not proposed, would be made, and that people's chances of survival would be reduced if the trust did not get its own way. It exhorted people to write into the consultation supporting its views, without giving a true picture of what is proposed, and it whipped up a climate of fear in the area. The Tory council then joined in the act, spending £42,500 on a letter to every household, signed by the leader of the council, who is the Finchley Tory parliamentary candidate. Again, it did not put the argument fairly, but I am pleased, or not pleased, to say that it gave the wrong details regarding how people should send their response by e-mail, so not many responses came in. That was rather a waste of £42,500 of council tax payers' money.
	That set off the local papers, which ran stories about NHS cuts, although no cuts, only an expansion of services, were proposed in our area. A headline in the Barnet press stated, "Council kicks out at NHS bid to ditch stroke unit", although there is no bid to ditch any stroke unit. Slightly more responsibly, the  Hendon & Finchley Times said:
	"Every minute you lose is crucial."
	There has been no attempt by NHS London or Healthcare for London to show a true picture of what is planned. There was not one effort to write a letter to the local papers explaining what is going on, so a good news story ended up as a cuts story by default. This is my question for my hon. Friend the Minister: when will the NHS get its act together in explaining what is actually going on? When will clinically led plans—that is what the plans are—be properly explained by clinicians to the public? Is it not time that the NHS had a decent communications strategy, with proper, objective, wide consultation on such major plans? If we can do that locally, why can it not be done London-wide, and why has the NHS simply ignored all that is going on? It is simply unacceptable, because the proposals are a good news story.
	Clinical evidence shows that patients are 25 per cent. more likely to survive or recover from a stroke if they get treated in a specialist centre. In London, there are big differences in the quality of stroke care. Rates of death in different hospitals vary considerably, and people in outer London have the most limited access to high-quality stroke services, which is why the proposals are particularly important. For some strokes, clot-busting drugs can stop and reverse the damage, but only after a high-quality scan has shown whether the patient is suitable for the drugs, so stroke patients need fast access to scanning facilities to have the best chance of recovery. Currently fewer than 10 per cent. of suitable patients are offered thrombolysis.
	So what is proposed? As I have said, the proposals are not a cut. The NHS plans to invest more than £23 million a year extra in new stroke services for London, with more and better trained doctors, nurses and therapists to deliver those new services. There is a proposal for eight hyperacute stroke units, which will provide the immediate response in the first 72 hours after a stroke, or until the patient is stabilised. They will be open 24 hours a day, seven days a week. Anyone having a stroke in London will be taken to one of them to have a brain scan. If appropriate, they will receive the clot-busting drugs within 30 minutes of arriving at the hospital.
	More than 20 stroke units will provide ongoing care once the patient is stabilised, and the transient ischaemic attack services will provide rapid assessment and access to a specialist within 24 hours for high-risk patients, or seven days for low-risk patients. Everyone in London will be within a 30-minute ambulance drive of one of those services. Obviously, the issue of how long that journey will take is a matter of contention. It is easy for us who drive around in cars to try to compare how long it would take us to do a journey with how long it would take a blue-light ambulance, but there is no comparison.
	The Tory leader of Barnet council—the Finchley Conservative candidate—has suggested that the figures are based on journey times at half-past 2 o'clock in the afternoon. As part of its analysis, Healthcare for London sourced the details of every single ambulance journey in London for three years—about 4 million records. It compared 100,000 blue-light journeys with 2 million other urgent ambulance journeys. It assessed the impact of the day of the week and the rush hour on the journey times, and it conducted a lot more detailed analysis besides. The figure is also backed up by the day-to-day experience of the London ambulance service in taking patients to eight specialist cardiac centres across the capital, so it is not surprising that the LAS supports the proposals. To give my own snapshot, I spent a shift driving around with the ambulance emergency services, and my experience supports the idea that the times are probably achievable.
	Locally, research by my PCT in Barnet shows that people living in deprived areas are more likely to die of vascular diseases, to smoke and to be obese, and they are thus at greater risk of having raised blood cholesterol levels, pre-diabetes, diabetes or high blood pressure. They are also less likely to visit their GP and have vascular disease risk factors identified and managed. There is thus a higher risk and incidence of stroke in the most deprived part of the borough—the west—which is my constituency. That has been confirmed by the opinion of the PCT medical director, Dr. Andrew Burnett, with whom I spoke last night. Northwick Park is easier to access from the west, my constituency, than Barnet hospital—a matter to which I shall return.
	For our part of London, consideration was given to Northwick Park, Barnet, University College hospital and the Royal Free. NHS London preferred Northwick Park to Barnet, because it provides better travel times and reflects existing patient flows. These arguments are supported by the London ambulance service. From my area the road to Northwick Park is mainly a straight, wide major road, whereas the road to Barnet is little more than a country lane.

Andrew Dismore: "The shape of things to come", the compact document which is easier to handle when making a speech, states:
	"We believe that hyperacute stroke care should be delivered in no more than eight sites across London"—
	this is on page 20. It continues:
	"This would optimise the number of patients being treated at each site, ensure expert teams are available 24 hours a day—improving survival and reducing disability".
	The hon. Gentleman will be aware that if the aim is to provide high quality very specialised services, it becomes an argument— [Interruption.] If he will stop intervening from a sedentary position and let me make the point, I shall be happy to give way to him again. The argument in this case is very much the argument advanced back in the early 1990s by the Government, whom he supported, for the closure of Edgware general hospital and the merging of the accident and emergency department there with that at Barnet hospital, on the basis that by creating a critical mass of patients, a higher quality service could be delivered.
	That is exactly what is being proposed in relation to the stroke units. If somebody were to convince me and Healthcare for London that an equally high-quality service could be delivered at Barnet hospital, I would have no objection. My concern is for my constituents—not for the whole of Barnet, not for Enfield, but for my constituents, who would find access to Northwick Park rather easier from the particularly deprived parts of my constituency than they would to Barnet.

Andrew Lansley: I had not realised that the consultation in London was somehow the fault of the previous Conservative Government, but then everything that the hon. Gentleman complains about is probably the fault of the previous Conservative Government. My point is not that some of his constituents should be advantaged by using Northwick Park rather than Barnet. I contend that there is nothing in the consultation document that demonstrates why it is not possible, as has been said, for example, by NHS East of England, for a large number of emergency departments to continue to offer acute care of stroke, including thrombolysis, as long as they are able to have, for example, immediate access to CT. The emergency departments of most hospitals increasingly have access to CT. The images can be sent somewhere else for interpretation—the specialist part—if necessary.

Andrew Dismore: I certainly do not hold the hon. Gentleman responsible for the consultation. His Government were not interested in spending an extra £23 million on services. They were interested in cutting services. The point that I am making is that a very similar argument was advanced by his Government for closing Edgware general hospital—that better A and E services could be delivered through the critical mass resulting from a bigger patient base at Barnet hospital than at the two hospitals, Edgware and Barnet.
	I listened to what the hon. Gentleman said, and no doubt my hon. Friend the Minister will respond to it later. We need a critical mass of patients to be able to deliver high quality services. We have a difference of view. Obviously, if it is possible to have stroke care at both hospitals, I have no objection, but if that is not possible, I prefer, on behalf of my constituents who live in the deprived part of the borough, the existing proposals for Northwick Park to the case for Barnet.
	We debated across the Floor the subject of UCH and the Royal Free. Preference was given to UCH, although I agree with the hon. Gentleman that the services at the Royal Free are of a very high quality. As I explained to him, I raised the matter with the Royal Free. It has accepted the proposal that it should work in partnership with UCH on the basis that UCH is able to provide better standards than the Royal Free at the National Hospital for Neurology and Neurosurgery, which is part of UCH. It is also important to point out that the Royal Free and UCH scored higher than Barnet on future clinical standards.
	Given the criteria in the consultation, I understand why Northwick Park was preferred to Barnet. It is important to recognise that the hyperacute units are only part of the story. I object to the scare stories run by the Conservative party that we will see the closure of stroke units and TIA units across London, which is not the case. As far as I can see, not only in my constituency but in my sector of London, those units will continue. That is the general picture, from what I know of other parts of the capital. It is wrong to suggest that those units will close and to scare people in that way.
	The TIA services for people who have had a mini-stroke will be provided at hospitals with hyperacute units or ordinary stroke units, as they are now. These assessment services will reduce the chance of someone going on to have a full stroke by up to 80 per cent. TIA and stroke services are provided at Barnet and at the Royal Free, as well as at Northwick Park and UCH, and they will continue to be there. The intention is to provide a comprehensive service, including the existing units at Barnet and the Royal Free.
	An additional point that I put forward in my response to the consultation was that I would like to see continuing care and rehabilitation services provided at Edgware community hospital as well. The rehabilitation services there have extra capacity, which could be expanded to deliver additional help in a constructive way and closer to home for patients suffering from the long-term after-effects of stroke.

Malcolm Moss: I begin by apologising to the Chair, the Minister, colleagues and Members in that I may not be in the Chamber for the full duration of the debate. I have other commitments at the Foreign Affairs Committee later this afternoon.
	Strokes are one of the most widespread and expensive conditions in the UK, costing the nation around £7 billion every single year, and on current trends the prevalence is set to increase at a worrying rate. Years of neglect in this area of public health policy have left the UK with the unenviable reputation of having some of the worst outcomes for stroke patients in the whole of western Europe.
	I was lucky enough in April to secure a Westminster Hall debate on cardiac and vascular health. May I take this opportunity to thank the Minister for honouring her commitment to answering the questions that remained outstanding at the end of the debate, and for the detailed responses that she sent me? It was during that debate that I highlighted the work of the Cardio & Vascular Coalition, which has published key recommendations for a new integrated approach to cardiac and vascular conditions for policy makers to consider.
	The 10-year national strategic framework is coming to an end but as yet we have no firm commitment from the Government to extend the strategy for a further 10 years. The British Heart Foundation, the Stroke Association, the British Cardiovascular Society and the Royal College of General Practitioners and many other smaller organisations which belong to the coalition would like the Government to give a commitment to the strategy. The 10-year mental health strategy has been renewed. Why cannot the framework strategy for cardiac and vascular health be renewed in a similar way? I await the Minister's response to the letter that I recently sent her on that point.
	Cardiovascular diseases, which include heart attack, stroke, diabetes and chronic kidney disease, affect the lives of more than 4 million people in England, cause 170,000 deaths each year, and are responsible for about one fifth of all hospital admissions. The challenge posed by those conditions is stark. Cardiac and vascular disease remains the No. 1 cause of death and disability in the United Kingdom, and strokes alone are the UK's third biggest killer—the second biggest if each type of cancer is counted separately—and the single biggest cause of severe adult disability. To our continuing embarrassment, the death rate for coronary heart disease and stroke in men and women is still higher in the UK than in comparable western European countries, and some risk factors for cardiovascular diseases, particularly obesity and a lack of physical activity, are increasing. On current trends, 60 per cent. of males and 50 per cent. of females will be obese by 2050, and, if unchecked, it is predicted that that will lead to a massive increase in type 2 diabetes, with the current trend indicating that more than 4 million people in the UK will have the condition by 2025. That, of course, will result in a large increase in the number of patients who require medication to prevent cardiac and vascular events.
	I welcome the national stroke strategy, which was launched at the end of 2007. Two central elements of the strategy are that patients should be admitted directly to a unit capable of undertaking immediate CT scanning and, where appropriate, undergo thrombolysis. It is absolutely crucial, as many contributors to this debate have said, that stroke victims are seen as quickly as possible. In that regard, I think that FAST, the new TV campaign, which has been mentioned on many occasions, has been successful. I commend the Government on their initiative in that regard.
	There is no doubt that, on the whole, hospital-based stroke services are improving and more stroke survivors have access to long-term care and support in the community. Yet, despite those developments, stroke services throughout England remain patchy and in need of considerable improvement. Sustained financial and political investment is therefore essential to maintain the momentum behind improving services that the strategy created.
	Rehabilitation and long-term support in the community remain the weakest element of the pathway for many stroke survivors. Previous investigation has found that only about half the individuals who experience a stroke receive rehabilitation that meets their needs in the first six months following discharge from hospital, with the figure falling to one fifth of individuals in the following six months. The Healthcare Commission's 2006 stroke patients survey showed that one year after discharge, more than half—about 54 per cent.—of patients said that they had not received any home help; that one third, or 32 per cent., had not received help with personal care; and that 45 per cent. had not received help with applying for benefits.
	I should like to put two questions to the Minister. First, what progress is being made in ensuring health and social care services work together to provide stroke survivors with a seamless transfer of care from hospital to the community? Secondly, what progress has been made in providing high-quality specialist rehabilitation and support for as long as a stroke survivor requires it?
	It is generally accepted that the Royal College of Physicians' national sentinel audit of stroke has provided an extremely useful tool for monitoring the implementation of standards and improvements in services in the acute sector, but there has not been a similar focus on monitoring community services for stroke survivors. Is it therefore the Government's intention to consider funding an extension to community stroke care of the RCP's auditing process?
	The operational plans for 2008-09 to 2010-11, entitled "National Planning Guidance and 'vital signs'", require PCTs to implement the stroke strategy. Monitoring will include, first, the number of patients who spend at least 90 per cent. of their time on a stroke unit and, secondly, the percentage of high-risk transient ischaemic attacks, or mini-strokes, that are treated within 24 hours. I am pleased to say that NHS Cambridgeshire, my local primary care trust, has responded positively through its newly published strategy. Indeed, as many contributors to this debate have emphasised, a key part of the strategy is prevention.
	NHS Cambridgeshire recently began a specific initiative in the 20 per cent. most deprived practices to implement vascular risk checks and proactively identify more people with risk factors for CVD who will then be added to the CVD risk register. It intends to offer practices a range of options for providing vascular risk checks to those people aged 40 to 70 years old, ranging from practices managing the vascular checks in their entirety, to working with a health adviser and community pharmacy-based provision.
	There is no doubt in my mind that in community pharmacies we have a fairly universal and readily accessible professional resource that could play a key role in an NHS health check programme. I strongly believe that community pharmacies could play a vital role in the battle against stroke by, for example, providing a regular blood pressure and cholesterol test. That new role seems to have been actively encouraged by parts of the NHS, but not universally. Some PCTs seem reluctant—through ignorance, professional opposition, lack of focus or simple tardiness—to embrace its great potential. I am delighted that NHS Cambridgeshire has alluded to the potential role of pharmacies, but it requires more than just a reference in a strategic document. A commitment to driving the concept through at ground level is vital, and I, for one, will monitor the PCT's progress.
	The PCT's strategy also means that patients will be identified with risk factors using the Framingham method, including those with post myocardial infarction and those with transient ischaemic attacks. It means also that patients alert will be utilised for GPs, indicating when preventative measures are required, in line with National Institute for Health and Clinical Excellence guidance. The PCT will continue to make the links to smoking cessation services, with a guaranteed recording of data on lifestyle and outcomes, and it will work with the public health directorate to support prevention messages, particularly in disadvantaged areas and groups. It is also vital to make appropriate links with the cross-government strategy for tackling obesity and with prevention work, in line with vascular checks. Finally, the PCT intends to roll out the scheme in the most deprived practices first. That will be of most benefit to my constituency of North-East Cambridgeshire, which has some of the highest deprivation indices in Cambridgeshire.
	The Government say that they are committed to evaluating the implementation of the stroke strategy, but how do they plan to evaluate its implementation, when will the Department of Health commission an evaluation of progress of health, what form will it take and when can we expect the results to be made public?
	In conclusion, stroke services are improving as a result of the stroke strategy, but there is still a long way to go to meet the standards contained in the 20 quality markers. Progress has not necessarily been made at the same rate throughout the country, and, in order to maintain and build on the achievements that have been made so far, continued investment will be required. In that regard, what plans do the Government have to ensure that improvements continue to be made after the current three-year funding round ends? How will the Government ensure that stroke remains a national priority?

Kate Hoey: I welcome the increased investment that the Government are putting in, but the danger to which my hon. Friend refers is there. There is always a danger that large super-duper elements in any provision will tend to take away from what most people want, which is good local services.
	I go back to the point about central London that I made in an intervention on the hon. Member for South Cambridgeshire. The consultation document's calculations for all the bed requirements do not take into account the non-resident population of London—the huge numbers of commuters from outside the city, the tourists and so on. The majority of those people come to central London. That is not to say that we do not need to improve radically the services in outer London areas, but I do not see the rationale for getting rid of the really good unit in central London—in the critical area of St. Thomas's, with its access to railway stations—to create something bigger elsewhere. King's college, Guy's and St. Thomas's hospitals are already working together, and they want to do so.
	There is a need for a radical approach to modernised stroke services in London, and much in the proposals is excellent. For example, this is the first time that standards have been set with clear requirements on the providers to deliver appropriate staffing levels. The issue, however, is about the actual model that has been chosen for London; that needs to be considered again. The people who are already working well in those hospitals and really know what is happening have not been listened to enough. NHS London needs to listen to the professionals, not entrench itself in what seems to be a fundamentalist approach. The approach needs to change; the primary care group that makes the decision in July needs to go back and make sure that it has listened and understood what is happening in the units that already do extremely good work.
	St. Thomas's serves diverse communities, which are more likely to be in need of a stroke unit. It also deals with commuters and all the tourists who come to central London. It has the expertise. The idea is to let that go to create a bigger unit at King's college hospital. Why do we not allow the two hospitals to plan and work out together what is in the best interests of the area? I hope that those making the decision at the end of the consultation will listen. If I had to choose between the expertise of Dr. Tony Rudd and that of members of the primary care trust, I know who I would support.

Andrew Murrison: I am grateful to the hon. Gentleman, but he needs to understand that there is a danger in extrapolating evidence from the sentinel study—I think that that is the one that he was citing—which came out just a few months after the implementation of the national strategy. Given that it is a 10-year strategy, and given previous trends, it would be extremely rash to suppose that it had had any effect at the time of the sentinel audit. I very much hope that the strategy will prove to be successful—I suspect that it will—but we need to be a bit careful about the language that we use in anticipation of that.
	It is important to compare this country's outcomes and incidence of disease with those nations with which we can reasonably be compared. In this context, I think particularly of western Europe. Standardised death rates from stroke among men under the age of 64 are nine per 100,000 in the UK compared with seven per 100,000 in France. The equivalent figures for women are seven deaths per 100,000 in the UK compared with four per 100,000 in France and in Spain. The UK has some of the worst outcomes for patients in western Europe. In one study, the differences between the UK and eight other European countries in terms of the proportion of patients left dead or dependent were between 150 and 300 events per 1,000 patients. That statistical material is rather technical stuff, but it points towards patients in Britain not doing as well as they have a right to expect, and it certainly suggests that there is no room for complacency.
	The Minister spoke about health checks and vascular risk assessments and invited the Opposition to support those initiatives. I have campaigned for many years for screening for abdominal aortic aneurysm, yet despite recommendations by the National Screening Committee we still do not have a credible roll-out of national screening for that particular condition. The Government need to be careful; interventions in the public health sphere, particularly in terms of prevention, need to be based on the evidence, which points towards instituting a screening programme expeditiously. I very much regret that that has not been done.
	What has changed over the past few years with stroke? It has gone from being a condition with chronicity to one that is seen as existing within the acute sector. It has become a medical emergency; of course, it always was, but it was not recognised as such. Unfortunately, as the Stroke Association observes, it is still not necessarily seen as a condition that requires immediate treatment and management—neither by potential patients nor, sometimes alarmingly, by health care professionals on the front line. That has been clearly shown by NOP and MORI polling over the past few years.
	Since the figures came out in October 2008, we have had the Department of Health campaign. We have all seen the television adverts that are part of that, which have been extremely good. The images are disturbing, but it is sometimes necessary to be fairly hard-hitting in order to change attitudes and behaviour. We will have to see whether the effects of that campaign are enduring. I was concerned to hear the hon. Member for Crawley, who has some experience in these matters, suggest that in a few years' time, when the funding runs out, we might simply move on to the next hot topic. Our approach needs to be a bit more long-term than that. As we have seen with road traffic campaigns, there is a danger that when we go on to the next topic we forget the public health messages that have been put across effectively, at least in the short term. That would be a great pity in the context of stroke. There have been a few measures of the campaign's effectiveness—for example, the Stroke Association has said that it has had more inquiries since the campaign kicked off in February. However, I should like the Minister to clarify what assessment the Government intend to make of its enduring effectiveness, which would, I hope, inform any future campaigns.
	If we are serious about public health and dealing with health inequalities, we have to address stroke, which is far more prevalent in less advantaged groups in our society, as well as in certain ethnic groups. We need to try to work out why that is and put in place measures to reduce that inequality. In my intervention on the Minister, I mentioned the effects of stroke on the rural poor. It is bad being poor, but it is particularly bad in a rural location where access to services is extremely difficult. Following my intervention, and that of my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), I wonder whether she has had any note from the Box about upgrading stroke from category B to category A, which is being considered by the Department's emergency call prioritisation group; if not, perhaps it would be possible to communicate separately on that subject. Such a step might be a way of improving access for people with stroke who live in rural areas.
	There is evidence that someone's chances of optimal management for stroke are best if they arrive at hospital by ambulance. However, according to the sentinel audit, only 17 per cent. of patients reach a stroke unit within four hours of arrival at hospital. I suspect that further work needs to be done in accident and emergency to improve triage and expedite the definitive management of stroke patients. That appears to be especially required at weekends, as, crucially, the chance of getting a scan, and therefore definitive treatment, is very much less out of hours.

Andrew Murrison: I am grateful to the hon. Gentleman for his intervention. I will deal with the question of specialist units versus district general hospitals in the remainder of my speech. However, his remarks spark me to reflect on the change in radiological protocols that have occurred in recent years. There has been a strong trend towards reducing the amount of elective work that is done out of hours. For example, it is now difficult to get a chest X-ray out of hours unless it is a real emergency, and very few are defined as emergencies requiring imaging. That is fine—it is absolutely right—but I sometimes wonder whether we have gone a little too far. I suspect that as part of the process, there is less willingness to do CT scans on stroke patients out of hours. We need to look again at our protocols to ensure that a medical emergency is investigated as such, 24/7.

Andrew Murrison: Yes, and I understand that the Minister's Department is doing that work at the moment. It is reviewing whether we should upgrade from category B from category A—from 18 minutes to nine minutes—the response time for stroke cases. It will be interesting to learn the outcome of that work. I suspect that part of the reason for the effectiveness of arriving by ambulance rather than under one's own steam, and the likelihood of getting prompter treatment when arriving by ambulance, is that triages are undertaken by ambulance crews. They are therefore able to pre-warn specialist stroke units that a patient will be arriving. Across a range of clinical areas we find that such warning expedites admission to specialist units, as patients do not have to go through the sieve of accident and emergency and the inevitable delay that is caused. I have some first-hand experience of that.
	Stroke services are somewhat patchy across the country. A postcode lottery applies, despite the fact that we have a national health service. The Stroke Association is concerned about that, as is the Royal College of Physicians, and the sentinel audit underscores that concern. In my own area, I find to my delight that according to the audit, the Royal United hospital and Salisbury hospital are reckoned to be good. However, my constituents go much further afield on occasion, and I find that Yeovil, Bristol, Weston and Gloucester are okay, but that Taunton and interestingly Swindon have much room for improvement.
	I caution against the evidence that has accrued about the use of specialist centres being used to favour large centres at the expense of district general hospitals. Stroke is not an obscure disease, it is a condition that strikes somebody in England every five minutes and the third most common cause of death in this country. The hon. Member for Hendon (Mr. Dismore), who is no longer in his place, talked about critical mass, which is important in the case of tertiary services. Nobody doubts that a patient should go to a tertiary unit for obscure conditions. Stroke is not unusual, it is bread and butter for district general hospitals. If it were removed from their responsibility, one would wonder about the foundations of the district hospital model. Quite honestly, a condition that causes the third most deaths in this country and sadly provides a patient every five minutes in England must be part of the underpinning of any acute service and part of its bread and butter.
	The investigation and treatment of stroke is not particularly complicated. In saying that, I do not underplay in any way the expertise of those who specialise in it. It relies upon a CT scanner—we are working towards a position where pretty well every hospital will have one—and access to telemedicine. In other words, a particular hospital does not necessarily need a specialist, because the information can be relayed and, crucially, a diagnosis made in that way. The treatment itself should not be beyond any acute unit in this country.

Andrew Slaughter: I shall begin by talking about some improvements in stroke services. From that, my hon. Friend the Minister can see where my speech will go towards the end.
	I make no apology for continuing to talk about London services, the increased investment in which is welcome. There has been £23 million of additional spending on stroke services, as my hon. Friend the Member for Hendon (Mr. Dismore) said. There is a predicted increase in survival rates of some 25 per cent. Notwithstanding the fact that, as he said, some deliberate misinformation has been put about by Opposition parties—I shall say something about that in a moment—it is interesting that all parties have taken on board the central point about the creation of hyper-acute stroke units.
	I tend to agree with what the Opposition have said about the strict adherence to numbers. The idea that specialist stroke treatment will be a major factor in saving lives over the next few years was initially received with some scepticism, but in the light of overwhelming clinical evidence it has now been widely accepted, which is a good thing.
	Like others, I pay tribute to my hon. Friend the Minister for her contribution, not only in her professional capacity and as a Minister but as my neighbouring MP. I was very pleased to celebrate the 60th anniversary of the NHS with her late last year at Charing Cross hospital, where she herself has worked and in which she continues to have a great interest and support me. The Minister of State, Department of Health, my hon. Friend the Member for Exeter (Mr. Bradshaw), who was briefly in his place, has been extremely helpful with regard to the difficulties that I have experienced in the current consultation.
	Finally, I pay tribute to the Stroke Association, which others have mentioned. It has done an excellent job in its recent report and in encouraging the Government and giving them praise where it is due. I do not say that only because when its staff were testing blood pressure in Portcullis House last month, they said that I had the blood pressure of a young man. I think is the only thing that I can claim to have about me that is of a young man.
	The current consultation ended on 8 May, and it has been mentioned several times this afternoon. The matter has been shockingly handled by Healthcare for London. I shall start by dealing with my simpler concern: the stroke unit at Ealing hospital. If the current proposals are implemented, that stroke unit will be closed. When I spoke to the neurologists and other professionals at Ealing, I found it was envisaged that the alternative provision would be at either Northwick Park or Charing Cross hospitals. Things have now moved on, and there is a worse plan. However, even at that stage, there was serious concern and some astonishment at such a proposal. I could speak for a long time about that one issue, and I am sure that other hon. Members could present arguments for hospitals in their constituencies or those nearby, which their constituents use extensively.
	Ealing hospital stroke unit provides good care, has just been refurbished to a high standard and is in the top 25 per cent. of stroke units in the country. It is by no means clear from the current proposal how the many people from the borough of Ealing and around who use the unit will be accommodated in future. There is no evidence that the capacity problems arising from the stroke unit's removal will be picked up by the alternative proposals. However, at least the proposal for Ealing is clear. The unit is to close and there is to be alternative provision. I repeat that the case for the need to hone provision to eight units and the case for their location have not been well made, but at least the decision is clear, if incorrect.
	The position of Charing Cross hospital, which is just outside my current constituency, but extensively used by my constituents, is far from clear. There is a proposal no longer to have one of the new hyper-acute stroke units there in the longer term. To avoid doubt and to be brief, I can do no better than read out part of my submission to the consultation. I said:
	"I do not accept that this consultation has been properly or transparently conducted and I believe the outcome of it—certainly as far as it affects my constituents—has been pre-determined."
	The right hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) made that point earlier. My submission continued:
	"I remain hopeful that I am wrong in this surmise, but if I am not I hope there may be some challenge, legal or otherwise to the proposals Healthcare for London are currently recommending for Charing Cross Hospital.
	Specifically, there is no clarity as to the process by which the preferred location of the fourth major trauma centre was switched at short notice from Charing Cross to St. Mary's Hospital. This having been done however, there is a preferred option for St. Mary's stated in the document with an attached footnote that the transfer of the hyper-acute stroke unit (HASU), currently proposed for Charing Cross, will in the space of two to three years follow the trauma centre to St. Mary's. I have spoken to clinicians at Charing Cross who believe this is the wrong course of action both in clinical and geographical terms. But this aspect of the proposal does not appear to be open for discussion. Rather it is the settled view of Healthcare for London that co-location is the sine qua non in deciding the location of this HASU.
	I do not see how Healthcare for London expect serious responses to such proposals which have all the appearance of being last minute, botched and above all so closely interconnected as to be incapable of being unravelled. I do not think the logistics of moving stroke and neurology services from Charing Cross to St. Mary's have been properly studied: the site, the funding and the relative size and importance of the clinical units at both hospitals strongly suggest the better option is building on the excellent provision currently at Charing Cross.
	I would like to be reassured that if as expected a HASU opens at Charing Cross later this year, if the proposal to move this to St. Mary's in 2012 or shortly thereafter is pursued there will be a full and impartial consultation at that time."
	The well respected and extensive stroke services at Charing Cross were to be combined with one of the major trauma centres for London, but the quality of the trauma bid was apparently not good enough, as was the case with the Royal Free, in which my hon. Friend the Member for Hendon has a constituency interest. Rather than those two bids being resubmitted, at short notice the trauma centre bid was switched to St. Mary's and that is now the preferred bid. It has been admitted to me in several meetings with health care professionals, the hospital trusts, the primary care trust, Healthcare for London and, indeed, the Under-Secretary, that it is a done deal: St. Mary's will be the trauma centre.
	Suddenly, as an afterthought, and done by asterisk and footnote in the consultation document, and clearly because the co-location proposal is sacrosanct, the stroke unit at Charing Cross, which is currently being prepared and will open, function and doubtless be extremely good for two years, will somehow move to the St. Mary's site, which is inappropriate. There is no provision for it and clinicians to whom I have spoken doubt whether there are funds for it. The proposal is a dog's breakfast, for want of a better phrase.
	There may be a guarantee of further consultation in future. That is not good enough. I have made the point strongly to the chief executive of Healthcare for London that no proper consultation has been carried out—that is clear from the document—and the matter needs to be revisited. Clearly, decisions have been made and put out for consultation thereafter.
	One of the unfortunate side effects is the mischief that can be made, and mischief aplenty has been made with the future of Charing Cross hospital for more than four years. It is a perfect site for a hospital; it is perfectly accessible. The decision affects not only constituents in Hammersmith and Fulham and Ealing but those in the entire London boroughs of Hounslow and Ealing and the wider area of west London, to whom Charing Cross is far more accessible than St. Mary's. The site is large, with plenty of room for redevelopment, which is already taking place. However, the botched decisions, the poor quality of decision making and the lack of information allow mischief to be made.
	There have been persistent rumours of downgrading or closure since 2005. The hospital was a major issue in the general election campaign. It suits the Conservative party locally to continue to keep those rumours alive and I have therefore been in conversation and correspondence with successive Health Ministers since I was elected to get assurances about the future of Charing Cross hospital. Those assurances are freely and readily given, and I have a copy here of the latest letter from the chief executive of NHS London, which is dated 29 May.
	The letter states that even if the hyper-acute stroke unit moves in due course from Charing Cross, the
	"stroke unit at Charing Cross hospital will be enhanced to deliver high quality stroke services for the people of Hammersmith and Fulham. We expect Charing Cross to retain a full range of services as a busy hospital for local residents maintaining its prominent position in the community."
	The letter goes on to say that the hospital will provide
	"a broad range of elective specialist services, as well as emergency services with the associated medical specialties, and an active A&E. It will continue to provide neurology and stroke services, including post 72-hour stroke care, rehabilitation and outpatient services."
	The chief executive could have added that one of the largest and most ambitious polyclinics is being built there, with a full GP practice on the side, in addition to many other new buildings, including the highly prestigious Maggie's cancer centre, which was visited by Sarah Brown and Michelle Obama on the President's recent visit. There is therefore no question but that Charing Cross has a bright and expanding future, with or without the hyper-acute stoke unit and trauma centre. Again, let me make it clear for the record that the Government are to be praised for that investment. In addition, since the formation of the Imperial health care trust and the Academic Health Science Centre, the prospects for health care in west London have never been better.
	However, the chief executive and the Minister can write as many letters to me as they wish, but what my constituents believe—because they are told so every fortnight in the only local newspaper in wide circulation, which is controlled by the Conservative council—is that Charing Cross is being downgraded or closed. That is deliberate disinformation, exactly as my hon. Friend the Member for Hendon said, put out with mischievous political intent by the Conservatives. However, they would not be able to do so were it not for the administrative confusion, complacency and lack of attention by health service managers in London.
	There is now a ridiculous conflict of interest, whereby the managements of the Conservative local authority and the local health service have fused. Therefore, the person who is charged locally, as the chief executive of what was called the PCT, with rebutting the accusation that the health service is not receiving investment, is being downgraded and is in decline, is exactly the same person putting out the propaganda saying that it is. The situation is quite surreal. I have raised the matter with Healthcare for London, but it prefers to make no comment. Just as in Hendon, where one part of the NHS is briefing against another, we now have a chief executive of the local authority who damns the health service in the morning and then, as the chief executive of the health service, tries to defend or praise it in the afternoon.
	That cannot be allowed to continue, because at bottom it affects my constituent's confidence in the local health service, which is excellent and improving. In my opinion, the only solution is to abandon at least those parts of the consultation that are discredited and were never consulted on in the first place, and which can only lead to a conclusion that is at best inadequate and at worst detrimental to patient care. I would ask my hon. Friend in responding to this debate to say that she will ask Healthcare for London to look at the situation again, because it is not satisfactory for us to go forward with, on the whole, an excellent proposal for stroke and trauma care—one that will improve services and save lives—without the certainty that things are being done with honesty and integrity, and in a way that will not confuse or undermine the health service in west London or people's opinion of it.

Brooks Newmark: I am delighted to follow the hon. Member for Wyre Forest (Dr. Taylor). I want to begin my speech on a personal note. My father-in-law, Sir John Keegan, had a stroke four weeks ago. He survived due to the swift response of his local ambulance service and the immediate care that he received at Salisbury district hospital in the critical first three hours following his stroke. I want to thank the doctors and nurses in the Farley unit at Salisbury district hospital for all their after-care in the past four weeks. In particular, my mother-in-law, Susanne, my wife, Lucy, my brothers-in-law, Tom and Matthew, and my sister-in-law, Rose, share my gratitude.
	As we have heard from my hon. Friend the Member for Westbury (Dr. Murrison)—in whose constituency my in-laws live—stroke is the country's third largest killer. It is also the single largest cause of adult disability, a point made by my hon. Friend the Member for Buckingham (John Bercow) at the beginning of the debate. We all have constituents who have been affected and I suspect that most of us may have experienced a stroke within our own families, as I did recently. Yet for too long, strokes have been the poor relation in the NHS, so I welcome the long overdue national stroke strategy of 2007, which finally prioritised stroke care for health and social care providers. Our response needs to be commensurate with the sheer size of the problem.
	The strategy has undoubtedly brought progress, but we must not stand still on the issue. Not enough patients are receiving the treatment and care that they need quickly enough and too many are subject to a dangerous postcode lottery. Inequalities in access to stroke units and long-term care all too often mean that where people live can dramatically affect the length of recovery from a stroke—or even whether they recover at all.
	If we want to improve stroke services, we must focus essentially on three elements: first, saving lives in hospital; secondly, reducing disabilities and long-term damage; and, thirdly, preventing strokes altogether. Speed is of the essence with a stroke. A scan and early treatment within the first three hours can, as we have heard, make the difference between complete recovery, a lifelong disability or even life at all. For example, a brain scan will crucially confirm the diagnosis of someone admitted to hospital. For people with ischaemic strokes, swift thrombolysis or treatment with clot-busting drugs within three hours will significantly reduce the chances of dying, yet last year, only 0.8 per cent. of patients received thrombolysis.
	I know that having a specialist stroke unit can do much to improve survival rates and recovery times for stroke patients. Commendably, early access to a stroke unit has improved significantly since 2006. However, in 2008, one quarter of patients were still not being offered this service—a service that I know, through personal experience, really can make a difference. As our population ages, the demand for these specialist units can only grow, so we must ensure that we can cope.
	Having swift and high-quality stroke services from day one makes sense for our country's financial health, too. Caring for stroke patients currently costs the UK about £7 billion each year because of the long-term implications of a stroke and the detrimental effects of delays in treatment. Given that about a third of stroke survivors will be left with a moderate to severe disability, long-term social care is often a necessity, not a luxury. However, the Stroke Association says that rehabilitation and long-term care in the community is one of the weakest elements of a stroke survivor's pathway. Only around half of those who have experienced a stroke receive the necessary rehabilitation in the first six months following discharge from hospital, which falls to a fifth in the following six months.
	The transition from hospital back to the community can also be extremely difficult. Not only do about a third of stroke survivors have communication difficulties—including, as highlighted in the Stroke Association's recent "Lost without Words" campaign, aphasia and speech impacts—but many experience a loss of confidence and independence as they struggle to regain their basic capabilities and rebuild their lives.
	I am pleased that as part of the national stroke strategy, every local authority now receives a ring-fenced grant of around £100,000 a year for stroke services. However, I believe that the scheme is currently intended for only three years, so just as services are really starting to make a difference, I fear they may be shut down for lack of long-term financial support.
	Finally, it is not enough to just to treat the symptom of the problem, as its cause is also important. We can reduce the likelihood of a stroke through preventive work on high blood pressure, irregular heartbeats and smoking, for example. That alone could prevent thousands of strokes each year, saving not only many families from having to watch a loved one suffer, but millions of pounds each year in care costs. For progress on stroke services, we must look carefully at three elements: the urgency of immediate health care; the long-term nature of recovery; and the opportunity to prevent strokes in future. Only if we can weave those into a more seamless approach, applied evenly regardless of where the patient lives, can we say that we are doing the best for the thousands of stroke sufferers each and every year.

Robert Wilson: From my direct experience, there is a problem. There are a significant number of pedlars, but the difficulty is proving that they have committed an offence. One has to watch pedlars pulling trolleys up and down the street for a long time—several hours. There can be six, eight, sometimes even 10 big trolleys—some are the size of a street stall. That is not easy to police and one has to watch carefully if one wants the prosecution to stick. It is a question of resources, and I sympathise with the police's problem, which is why it is probably better for the local authority to play a bigger role in policing peddling.
	Rather than expecting the police to take action against pedlars, it is much better that local authorities should have sufficient powers to regulate the offending behaviour themselves. Richard Bennett also reiterated the fact that neighbourhood policing is not intended to address all the licensing and trading issues that the local authority is meant to control. The local police response was that Reading borough council has a responsibility to create the sort of conditions in the town centre that will help legitimate street traders to prosper.
	The upshot of the police response is simple. Although each case is complex, giving limited additional powers to other agencies, such as Reading borough council, would increase the range of options available to all authorities to put sensible measures in place. Although I would not wish to generalise about other forces across the country, Reading police made it clear that it sees the Bill not as being about handing over power to the council, but as being about sharing responsibility, which will make enforcement action much quicker and more coherent.
	That is a logical and sensible approach. If the Reading Borough Council Bill is passed, it would undoubtedly free up the police's valuable resources to address more pressing issues in the Reading area. Steve Kirk, Reading's local police area commander, has also written in support of the application for a change in the legislation, which, as we know, dates back to 1871. He says that the 1871 Act is now simply not fit for the purpose of controlling the activity that it was originally intended to control.
	I want to draw hon. Members' attention to the comments made by my hon. Friend the Member for Cotswold (Mr. Clifton-Brown) in our previous debate. He advocated dealing with the problem through an overarching, national solution, rather than through piecemeal legislation. He rightly asked: if the Reading Borough Council Bill receives Royal Assent, what is to stop other local authorities from seeking the same legislation in their town centres? Not only would valuable parliamentary time have to be found for each separate Bill, but there would be a detrimental effect on the public purse.
	That is a serious point, because I understand that each such Bill that is brought to Parliament costs about £100,000. I understand that a portion of the cost of the Reading Borough Council Bill is being funded by the business improvement district, but perhaps there are better ways of spending local taxpayers' money than bringing forward such Bills from across the country in the way that we are. I am digressing slightly, Mr. Deputy Speaker, but with 50 Bills in the pipeline, a significant amount of public money would be needed to try to take them all through Parliament.
	There is an argument that much of the current private legislation would be unnecessary if the Government agreed to a national legislative framework. Indeed, some hon. Members argued strongly for that in previous debates. That is one reason why I read with interest the research conducted by St. Chad's college, Durham, to which my hon. Friend the Member for Shipley has referred, that was commissioned by the Department for Business, Enterprise and Regulatory Reform. That research raised several interesting points that are worthy of mention in this debate in relation to Reading borough council.
	The research concluded that the scale of pedlary in the UK is relatively modest—although one would not know that from some of our debates—with an estimated 3,000 to 4,500 people being granted certificates by police forces across the country. The study found little evidence that certificated pedlars present problems in most city centres or that they are in direct competition with shops or street traders. The evidence also suggested that consumers value pedlars' presence in town centres and regard buying from them as a positive experience, as I found when I was out looking at the issue in Reading town centre. The study ended by stating that there is no need for national legislation, although solutions may be required to deal with local problems in particular areas.
	Although I have already highlighted the legal anomaly that would arise because of the split of my constituency into two areas under separate local authorities, I believe that the conclusions of the report are sensible and fair. It says that the most common desire of local authorities is to be able to exercise more flexible and powerful sanctions, such as the ability to seize goods, issue fixed penalty notices and move traders on. However, the most evident concern related to the issues of obstruction or public safety caused by large numbers of street traders gathering in small areas, such as around football grounds or in city centres in the run-up to Christmas. My experience in Reading town centre is that large numbers of pedlars gather there with their big trolleys. At certain times, that causes an obstruction and becomes a public safety issue for my constituents. There is therefore a need for action in that area.
	Pedlars and police respondents to the research by the university of Durham also recognised the need to modernise and standardise, rather than repeal or replace, the 1871 Act. The inadequacies of the present system lead to inconsistency in enforcement practice between areas, which is exacerbated by a degree of ignorance among enforcement officers. I am sure that we all agree that greater clarity on this issue is needed for enforcement officers and pedlars alike. Interestingly, many of the local authorities that submitted evidence said that there were few, if any, difficulties stemming from illegal street trading. Only half the local authority respondents wished to change the existing legislation. This shows that, while certain councils—Reading included—wish to add to their statutory powers, many are happy with the status quo. Such information raises concerns about how important the new legislation really is. The Durham research concluded that possible changes to procedures relating to pedlars could include a more concrete nationally applicable set of definitions and guidelines relating to the issuing of certificates and to pedlars' activities, the redesign and standardisation of the pedlars' certificate and a greater burden on the pedlar to prove that they are a legitimate trader.
	As a former entrepreneur—indeed, I still like to think of myself as a businessman—I strongly believe in the right to free, open and fair trade. I do not wish in any way to be seen to be against pedlars, because legitimate traders have a rightful place on every high street and add to the colour and diversity of our towns and cities. I do not want this legislation to drive out the genuine pedlar. However, I also do not believe that an ambiguity in the law should enable certain individuals to flout the rules at the expense of others.
	Having aired these arguments and raised a few points of continued concern, I am going to support the Bill on this occasion, but on the clear understanding that my hon. Friend the Member for Christchurch—whose diligence must be commended—has brokered a very sensible compromise with Reading borough council. I congratulate the borough officer responsible, Clare Bradley, on agreeing a sensible compromise that all parties, including myself, appear to be happy with. That compromise will allow pedlars to continue to trade in the heart of my constituency, but without using the massive rolling trolleys to which I have referred. They are more akin to street traders' stalls on wheels, and they allow unfair competition. The pedlars will be able to trade in the more traditional way intended, and their enterprise will therefore be properly rewarded. I welcome the compromise and will therefore not detain the House any further.

Gareth Thomas: This has been an interesting debate, which has carried on from previous discussions of similar private Bills.
	I acknowledge the contribution of my right hon. Friend the Member for Leeds, West (John Battle), who is a great champion of his city. He made a short, concise but nevertheless significant speech in favour of the Leeds City Council Bill, backed up by my hon. Friend the Member for Leeds, North-East (Mr. Hamilton). My right hon. Friend noted in particular an amendment proposed by Leeds. I share his regret at the absence of the hon. Member for Christchurch (Mr. Chope)—I am not sure he will welcome the Government wishing him well in his recovery, but I do so nevertheless.
	The hon. Member for Shipley (Philip Davies) made a series of interesting points, and has clearly being doing his research. As part of that, I hope he is now reading the Department for Business, Enterprise and Regulatory Reform website—a confession to which he alluded in previous debates—more thoroughly and rigorously. I am happy to be corrected by him, but he seemed to argue that either there is a national problem in relation to pedlar legislation and the way in which pedlars are handled or there is not. Although I acknowledge the number of private Bills that have been brought to the attention of the House, the number of local authorities across the UK that have not sought to introduce legislation on the issue to date is also worth noting.
	There has been growing pressure on the Government to consider the issue. My hon. Friend the Member for Bolton, South-East (Dr. Iddon) has been particularly astute in his consistent lobbying of the Government to take action. As the House knows, we have responded to such calls.

Gareth Thomas: I do not necessarily accept that that is the case. Where local authorities face problems, they have sought a private Bill in the usual way to address local issues. I also acknowledge that a growing number, albeit a minority, of local authorities have been concerned about how pedlar legislation has been used, and have made the case for reform. In that spirit, we have sought to conduct the research led by Durham university, to which I will refer in a moment.
	My hon. Friend the Member for Reading, West (Martin Salter) again made a passionate and powerful speech in favour of the Reading Borough Council Bill. The hon. Member for Reading, East (Mr. Wilson) also made a thoughtful and considered case for the Bill. I was almost sympathetic to his plight as my hon. Friend the Member intervened on him: his interventions made me grateful that he continues to be on my side. My hon. Friend the Member for Nottingham, East (Mr. Heppell) also made a passionate defence of his city's need for the legislation under consideration.
	For the convenience of the House, let me set out the Government's updated thinking on the issues. In March, during the revival debate on these and three other private Bills, I confirmed that my Department would undertake a consultation this summer on street trading and pedlary, as a result of the research findings set out in the Durham university report, which my Department commissioned last year. As I have said, we hope to launch the consultation by the summer recess. Details will appear on the DBERR website in the usual way, and no doubt the hon. Member for Shipley will be one of the first to spot them.

John Hemming: I welcome the consultation on the Pedlars Act. May I ask the Minister, however, whether in the future he might recognise that £100,000 is a relatively high threshold, and that nothing should necessarily be read into the fact that local authority nuisance has not reached the threshold of £100,000 worth of expenditure?

David Heath: I support the hon. Gentleman strongly on this matter. As he knows, the circuit includes many Somerset towns—no one outside Somerset has any concept of the scale of Somerset carnivals—so pedlars are a real problem throughout the county. As he knows, his predecessor tried hard to get the law changed to deal with the problem. I hope that through the process of private Bills, the Government will eventually recognise that the prevalence of pedlars are a problem for the charitable sector as well as for commercial traders.

European Working Time Directive (Fire Fighters)

Andrew George: I certainly agree with the hon. Gentleman but, having said that, I think that the one area where a certain amount of power is available to local authorities, in which—surprise, surprise, perhaps—there is often more competition among selected members to go on to the relevant committee, is planning. In fact, the planning committees make decisions on the economic, residential and other development of their communities. That happens very much at a local level and is, admittedly, site-specific and is applied case by case, but that committee has more power. I agree with the hon. Gentleman that that power is not sufficient to allow the committee to direct development in the way I believe local authorities should be entitled to, but planning is probably the area in which local authorities have most power. If the hon. Gentleman reflects on that, he will see that it means that in all other areas of local government, powers are extremely restricted.
	It is also worth reflecting for a moment on the Government's record on regional government and regional government powers. Although I do not intend to take up a lot of time on this issue—it is one that has been widely debated on many occasions—it is perhaps worth reflecting that the Government set out with an honourable objective, which was to try to establish regional government across the country. They rightly set out to deliver devolution in Scotland and Wales and, as part of the peace process, in Northern Ireland. They set out to do so in London, too, of course. That was an appropriate approach to the concept and policy of delivering devolution across the UK.
	Of course, devolution is a process rather than a single event, and those who understand how the process works recognise that. When addressing the issue of the vacuum or lack of devolved power in the rest of the country, the Government seemed to forget that the fundamental principle of devolution is that it is a process of letting go, rather than holding on for dear life. I would have hoped that, after 12 years in power, the Government might have had the opportunity to reflect on that but, disappointingly, so far they seem not to have done so.
	I say that devolution is a process of letting go rather than holding on, because the Government appeared to take the view that they should define the boundaries of the so-called regions—I call them Government zones—in which powers were supposedly to be handed down. They also set the timetable by which they would deliver those powers. They set out the basis on which the north-east referendum of 2004 would be held. In all senses, the devolution process was very much led by central Government.
	I do not come from the north-east; I come from the diametrically opposite end of the country. I come from the far west of Cornwall—the bottom left-hand corner, as it were. If the Government said to Cornwall, "We'll offer you regional government based on these boundaries, these powers and this timetable. Now this is the question: do you want it or not?", I am afraid that a lot of people would be rather sceptical and would think there was a centrally driven agenda. The Government have retreated into a rather unhappy netherworld, having established Regional Select Committees, for which there is no cross-party consensus or support. Those Committees are a means of replacing the unelected regional assemblies, which the Government are to abolish; that is about as far as they have managed to go in the devolution of regional powers.
	In some senses, in some parts of Government there is a passion genuinely to deliver regional powers—there is recognition that the state is far too centralised. I hope that the Government will open the issue up again, and not come at it from the angle of believing that they can control the agenda in the way they have done. They should set a menu of powers and allow local authorities themselves to decide, perhaps in the same way that they are enabling that to happen through the multi-area agreements. However, I do not think those agreements go far enough, or will in any sense deliver what I believe the Government should deliver.
	The Government should allow communities to come together to draw up their own plans for devolved regional settlement, for taking powers away from the quangos, and for allowing decisions instead to be taken by directly elected representatives of local communities, who can shape and steer the ways their communities develop. If the Government were to allow that to happen, it would be easier to recognise that local government itself could be developed following the same principle—the principle that decentralisation is not just a process but is about letting go rather than holding on to the agenda. I hope that that is what the Government will do.
	As the Under-Secretary of State for Communities and Local Government, the hon. Member for Tooting (Mr. Khan), knows full well, Cornwall county council and the six district and borough councils in Cornwall went through a painful process, which involved a lot of recriminatory and unsatisfactory debate of the kind that I described to him a moment or two ago, in the lead-up to the establishment of a single unitary authority. Elections to that authority take place tomorrow.
	Cornwall put forward two possible patterns for the delivery of a single unitary authority, which I know the Government considered carefully. One proposal was for a single unitary authority with 18 local delivery areas or community networks; the other proposal was for six local delivery areas, reflecting the existing six districts. Both were unitary options. They seemed to be in conflict with each other, but in many senses they were similar bids.
	When it came to a decision on the option that the Government went along with, which was the county council's version of the single unitary authority, the debate was not very satisfactory. Many people in Cornwall felt that there was insufficient consultation. Those who were unsuccessful at the district level, if I may say so, engaged in a recriminatory political campaign to try to stop the initiative going through.
	Many of us felt that the process may be worth pursuing if the Government were prepared to give Cornwall some real decision-making powers, but as the negotiation went on it became clear that the Government would not offer Cornwall any meaningful additional powers. It would be the same, but larger, agent of central Government as before, when there were seven authorities. That was a great disappointment.
	In the vote on the order last year, I voted, with great regret, against the proposal. I felt that it should be taken away and worked on again, with the Government contributing a great deal more to the process of establishing a stronger tier of government in Cornwall. However, the decision is taken not in Cornwall but in Parliament, and Parliament saw to it that the order went through, so the unitary authority is being set up. As the Minister knows, it has established its interim board, which has been in operation since 1 April, and the first elections for 123 members will take place tomorrow.
	In spite of having been opposed to it, I want to ensure that the council is a great success. The Government need to recognise that, underlying a rather frustrated local government sector in Cornwall and a rather disenchanted electorate—we will see by Friday evening what result they produce for us—there is great ambition for Cornwall. In any area there is the silliness of the extreme fringes, but Cornwall, with its own language, history and strong constitutional status on account of the Duchy, has strong arguments to promote its diversity and cultural strength. It is not a case of Cornwall wanting to cut itself off from the rest of the country and to become rather nationalistic and narrow, but rather of Cornwall wanting to enter into the celebration of diversity in the UK and the wider world, but it can do that only from a position of strength, not if it has little latitude to take decisions.
	Cornwall's great ambition is to be the United Kingdom's green peninsula. We already have more wind turbines, the Government support the wave hub experiment off the north coast of my constituency. and in Cornwall there are some excellent companies operating in the geothermal and renewables sectors. In Cornwall, there is a lot of imaginative thinking and there are many excellent people to drive that agenda in the county itself. There is a real passion and ambition to champion social justice and to create the conditions for a more equal society. There is an ambition also to put our young people at the centre of policy making, but it is currently difficult to do so given the resources that are available and the way policy is directed from the centre. The careers service and other services are not under local control.
	There is an ambition to build a powerful brand for Cornwall, but that is difficult when the regional development agency covers the Government zone of the south-west, stretching from the constituency of the hon. Member for Stroud (Mr. Drew) down to my constituency, which includes the Isles of Scilly. The south-west, as a Government zone, really has no brand. There are many lovely places in it, and it is worth their establishing their own brands, but there is no such thing as that south-west. It has been difficult to generate any enthusiasm or support from the regional development agency for something that it fears is about promoting a brand within the brand that it wants to create for that invented region.
	We also have an opportunity to rediscover the distinctiveness of Cornwall, to build on the cultural and environmental strengths of the county, to be outward-facing not inward-looking and to develop our communications and maritime industries. When the Government look at transport both in Cornwall and, strategically, within the RDA zone, they see the area as some kind of landlocked appendage and worry how much tarmac there is and whether the roads and the rail services are adequate, as if all communications in Cornwall travel just east to west. In fact, Cornwall is almost surrounded by sea and, seen from a much wider perspective, faces out to a much wider world. It has maritime connections, is three miles from the busiest shipping lane in the world, has the second-largest natural harbour in Europe, at Falmouth, and so on. All that potential is being ignored, and Cornwall is simply seen as a pleasant holiday destination.
	Cornwall should have the power to shape those matters and its own future. After all, who should decide how many homes are built in Cornwall? The hon. Member for Shipley (Philip Davies) mentioned planning powers, and I know that it is highly contentious both in the House and in local authorities. The Government want to develop 3 million homes by 2020, but Cornwall has undergone such development. We have not tried to resist it, because the county is one of the fastest growing places in the country. It has had the third fasted housing development since the early 1960s. In the past 40 years, Cornwall has more than doubled its housing stock, yet over that period the housing problems of local people have become, if anything, far worse. Simply building houses—heaping up thousands of houses—is not the answer. As far as the plans for Cornwall are concerned, the decisions are taken outside the county. The south-west assembly, as it called itself before it was abolished, was engaged in the process of deciding what the regional spatial strategy should look like. It came up with a figure, which was then overruled by the Secretary of State; one wonders why it bothered in the first place.
	Cornwall now has to have 70,000 houses during the 16 or 17 remaining years of the plan. However, having experienced the highest housing growth anywhere within the Government zone, and very high housing growth in the context of the UK overall, we in Cornwall know that simply adding all those houses will not address housing need. We need to establish policies that enable local authorities—in Cornwall's case, the local authority—and local communities to drive a development process that meets local social housing need.
	In my part of the world, a large proportion of properties are second homes; 10 per cent. in Penwith district are, for example. I have nothing against the people who own those homes, but they clearly have an impact on local people's ability to purchase a property locally. Just last year, I did a survey of estate agents in my constituency, and it showed that three times as many properties were sold to second-home buyers as to first-time buyers. That is the pattern in the housing market of my area. As I have said, simply building more houses is not the answer. People who want to buy second homes will clearly be better able to buy those houses than local people on local wages—in Cornwall, we have the lowest wages in the country. We have to do something rather more sophisticated than simply dumping 70,000 houses in Cornwall. The four western districts of the county are already among the four most densely populated rural districts in the Government zone, so it is not as if a wealth of development land available is available.
	Who should decide how many homes should be built in Cornwall? Should it be a Government quango or people elected to the local authority? If we ask people there, they will say, "We want a say on this matter." I am talking about Cornwall, but if people in any community are asked whether a Government board or people who represent the local community should decide whether 15 per cent. of money spent on elective surgical work should be diverted to private hospitals rather than NHS hospitals, the answer will be clear. People believe that decisions about their local NHS should be made by local people, not by a process that comes down from central Government.

Philip Davies: I do not intend to detain the House for long, but may I first congratulate the hon. Member for St. Ives (Andrew George) on securing this Adjournment debate? This debate is about a vital issue that affects all our communities, including those in my part of the world, and clearly in his too. I commend him for that.
	I also commend the hon. Gentleman on his speech, which was extremely thoughtful, thought provoking and interesting. He hit the nail on the head many times in talking about the issues that local people are concerned about. There is genuine concern about the relationship between central Government, regional government and local government.
	However, one thing that the hon. Gentleman did not touch on, but which may be a fruitful topic for another time, is—to go further down the line—the role of parish councils and where they fit in. Local residents often see parish councils as expensive talking shops, but if they were given the powers that in my opinion they deserve, we could have genuinely local decision making and they would become more much powerful in the local communities that they serve. However, that debate is probably best left for another occasion.
	I was particularly struck by the hon. Gentleman's opening comments about how the relationship between local government and national Government has become more centralised, but not just under this Government, although the situation has got worse. He was right that that has happened under successive Governments of all political persuasions. Let me consider briefly why that might be the case. When a party is in government and people wish to protest about what that Government are doing, they often do so in local elections, which means that the political make-up of local government is often very different from that of central Government. Not wishing to give up their political power, central Government therefore decide to centralise powers, so that their political opponents cannot have them locally. We need a change of culture in central Government, so that they are more relaxed about people from different political parties having local control, because at the end of the day, that is what local democracy is all about. If people decide that they want a party in power locally that differs from the Government of the day, so be it. That is what local democracy is all about. Central Government should be much more relaxed about that and not try to keep all the power for themselves.
	In my intervention on the hon. Gentleman, I touched on planning. In my part of the world, planning is the most emotive issue, in respect of the power of local authorities, and it is probably the one that exercises people more than any other. I have great sympathy for local councillors, because they are often put in an invidious position. They get the blame for decisions that are nominally taken locally, but they have little responsibility in shaping the outcome, because those decisions are actually made at a higher level, whether it be at the regional or central Government level. Councillors are put in an extremely difficult position. I would like much more power to be given to local government, which does matter to people. People identify with their local authority and their local area, and they respect that institution. We should be much more relaxed about giving local authorities far more power to determine what are clearly local matters.
	No local matter is more important than planning. My constituents are sick to the back teeth of seeing more and more completely unwanted developments going up. Those developments change the nature of the villages, but people feel that they have absolutely no control over the decisions involved. They also feel that the local authority has little control over them. This problem manifests itself in different ways. Sometimes it is about garden developments. I have seen the nature of villages in my constituency change as a result of houses being crammed into every possible part of the village, often in people's gardens. However, local people find that the biggest handicap they face in dealing with the matter is not the local authority, which is often sympathetic to their concerns.
	The problem is often that the sites are designated as brownfield sites, rather than greenfield sites, and that the planning laws are stacked against those who object to the proposals. A local authority might decide that a piece of land forms an important part of the green belt, or that it is of local significance and should be left alone, only to have a planning inspector overrule that decision and put the area into a development plan against the wishes not only of the local people but of the local authority. The land is then developed even though no one in the local area wants that to happen. Such decisions should be made at local level.
	I listened with interest to the intervention by the hon. Member for Leicester, South (Sir Peter Soulsby), who was a distinguished local government leader. I certainly respect his experience in these matters, but I am not sure that I entirely agree with the premise of his argument. He suggested that these matters often had to be decided at a higher level because local authorities were full of nimbys and if the decisions were left to them, nothing would ever get built. Perhaps I am simplifying his argument slightly, but that seemed to be the thrust of it. I do not accept his point. If we believe that there is a need for more housing, presumably that need is expressed by local communities themselves. Presumably, people are saying that their daughters, sons and grandchildren cannot find anywhere to live and that more housing is therefore needed. The Government are for ever telling us that we need more housing because all these different categories of people are finding it difficult to get on to the housing ladder. If that is the case, surely local government is just as capable as central Government of responding to those local needs.

Sadiq Khan: Tempting as it is to spend the time responding to the interesting contribution of the hon. Member for Shipley (Philip Davies), I will try my best to respond to the 21-page essay, which I read late into this morning, and the 43-minute speech of the hon. Member for St. Ives (Andrew George). If there is time, I will then respond to the interesting points made by the hon. Member for Shipley.
	I congratulate the hon. Member for St. Ives on securing the debate. I was pleased that the House's other business finished early, as it allowed the interventions and contributions of other hon. Members to be heard, and it gave him the flexibility to make his speech in a tempered and serious manner. I am pleased that he continues to show a keen interest in matters relating to the balance of powers between central and local government, and that the hon. Member for Shipley and my hon. Friend the Member for Leicester, South (Sir Peter Soulsby) also contributed to the debate. The enthusiasm of the hon. Member for St. Ives for discussions on this topic knows no bounds, and I was delighted to observe from his request for the debate that his membership of the Select Committee on Communities and Local Government had further fuelled his appetite.
	The hon. Gentleman quoted extracts from the Select Committee's recent report on the balance of powers between central and local government. I welcome his work and that of other members of the Committee. As he will know, we published an immediate response to the report. A detailed response will be produced in the not-too-distant future, but he will appreciate that for constitutional reasons none of the comments that I shall make today should be taken as a formal response.
	Let me put into context some of the relationships between local and central Government before dealing with some of the points raised in his "essay", as the hon. Member for St. Ives called it. The Government strongly believe that local authorities are best placed to know what their communities need. I was a councillor for 12 years. I am aware of the work done by my hon. Friend the Member for Leicester, South in this context, and my hon. Friend the Member for Ipswich (Chris Mole), the Whip, has been a distinguished council leader as well. The Government know of the huge contribution made by local authorities, which is why we have taken unprecedented steps to put much more power into the hands of local government.
	Keen historians will know—as will the hon. Member for St. Ives, who has been a Member of Parliament since 1997—that since that year local authorities have gained significant powers, responsibilities and financial freedoms from central Government to enable further devolution of decision making to local communities. I could not but agree with the opening observation by the hon. Member for Shipley that one of the reasons for central Government's nervous relationship with local authorities might be a result of their different politics. He will recall that one of the justifications given by a former Prime Minister—I am going back four Prime Ministers—for abolishing the Greater London council was her affection for the then leader of the GLC. The hon. Gentleman made a fair point, but I think that even he would have to accept that over the past 12 years an attempt has been made to reverse some of the removal of power that took place during the preceding period.
	Key legislation over the past decade has brought about a new relationship between central and local government and between local government and local people. I shall say more about that shortly. It has led to a marked shift in the culture in local authorities, featuring a much stronger focus on performance management and effective leadership on delivery. In particular—as the hon. Gentleman will know—the 2006 local government White Paper signalled devolution of power from Whitehall to town halls, and from local authorities to local communities in England. It set out ways of giving local authorities and their partners more freedom and powers to meet the needs of their citizens and communities, and to enable those citizens and communities themselves to play their part in bringing about the changes they wanted. The hon. Member for Shipley mentioned some of the key changes produced by the Local Government and Public Involvement in Health Act 2007 following the White Paper.
	The hon. Member for St. Ives spoke of the "control freakery" involved in a referendum that can lead to a negative vote. He will, of course, recall the vote in Wales which led to a Welsh Assembly, the vote in Scotland which led to the Scottish Parliament, and the vote in London which led to a Greater London Assembly and a Mayor of London. It is not always the case that local people vote against the regions in referendums.

Philip Davies: Could the Minister comment on matters such as local transport? In my constituency, the local residents and the local council want to do something about a congested area, Saltaire roundabout, but they cannot get the funding because it is determined by an unelected regional transport board? Could not these powers be handed down to local authorities, so that local people could have a better say in how money is spent? At the moment, with the regional transport board, they feel that they have no say.